Inaccurate MDS Assessment Coding for Resident Mobility
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessments accurately reflected their physical status. Specifically, a resident admitted and later readmitted with multiple diagnoses, including heart disease, anemia, and hypertension, had conflicting MDS documentation. The admission assessment indicated no impairment in upper and lower extremities, while the subsequent quarterly assessment documented impairments on both sides of the upper and lower extremities. Observations of the resident showed the ability to move both arms and support their chin, which contradicted the quarterly MDS assessment. Upon review, the MDS nurse confirmed that the quarterly assessment was mistakenly coded as showing impairments, when it should have indicated no impairment.